title: The adverse effect of emergency department crowding on compliance with the resuscitation bundle in the management of severe sepsis and septic shock.
abstract: BACKGROUND
  The aim of this study is to evaluate the effects of emergency department (ED) crowding on the implementation of tasks in the early resuscitation bundle during acute care of patients with severe sepsis and septic shock, as recommended by the Surviving Sepsis Campaign guidelines.
  
  
  METHODS
  We analyzed the sepsis registry from August 2008 to March 2012 for patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. The ED occupancy rate, which was defined as the total number of patients in the ED divided by the total number of ED beds, was used for measuring the degree of ED crowding. It was categorized into three groups (low; intermediate; high crowding). The primary endpoint was the overall compliance with the entire resuscitation bundle.
  
  
  RESULTS
  A total of 770 patients were enrolled. Of the eligible patients, 276 patients were assigned to the low crowding group, 250 patients to the intermediate crowding group, and 244 patients to the high crowding group (ED occupancy rate: ≤ 115; 116-149; ≥ 150%). There was significant difference in compliance rates among the three groups (31.9% in the low crowding group, 24.4% in the intermediate crowding group, and 16.4% in the high crowding group, P < 0.001). In a multivariate model, the high crowding group had a significant association with lower compliance (adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.26 to 0.76; P = 0.003). When the ED occupancy rate was included as a continuous variable in the model, it had also a negative correlation with the overall compliance (OR of 10% increase of the ED occupancy rate, 0.90; 95% CI, 0.84 to 0.96, P = 0.002).
  
  
  CONCLUSIONS
  ED crowding was significantly associated with lower compliance with the entire resuscitation bundle and decreased likelihood of the timely implementation of the bundle elements.
authors.forename: Tae Gun
authors.initials: TG
authors.lastname: Shin
authors.forename: Ik Joon
authors.initials: IJ
authors.lastname: Jo
authors.forename: Dae Jong
authors.initials: DJ
authors.lastname: Choi
authors.forename: Mun Ju
authors.initials: MJ
authors.lastname: Kang
authors.forename: Kyeongman
authors.initials: K
authors.lastname: Jeon
authors.forename: Gee Young
authors.initials: GY
authors.lastname: Suh
authors.forename: Min Seob
authors.initials: MS
authors.lastname: Sim
authors.forename: So Yeon
authors.initials: SY
authors.lastname: Lim
authors.forename: Keun Jeong
authors.initials: KJ
authors.lastname: Song
authors.forename: Yeon Kwon
authors.initials: YK
authors.lastname: Jeong
mesh_terms: D000368:Aged; D003441:Crowding; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012042:Registries; D012151:Resuscitation / Q000592:standards*; D018805:Sepsis / Q000401:mortality / Q000628:therapy*; D012772:Shock, Septic / Q000401:mortality / Q000628:therapy*